Updated: 5/17/2022

Lumbar Disc Herniation

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  • summary
    • Lumbar Disc Herniation is a very common cause of low back pain and unilateral leg pain, known as radiculopathy. In rare cases a large disc herniation can lead to Cauda Equina Syndrome which requires emergent diagnosis and treatment. 
    • Diagnosis is made clinically and confirmed with an MRI studies of the lumbar spine.
    • Treatment for radicular leg pain is initially nonoperative with oral medications and physical therapy.  Surgical microdiscectomy is only indicated for severe pain and/or motor deficit that have failed to respond to nonoperative management. Treatment for Cauda Equina Syndrome in contrast is emergent microdiscectomy within 48 hours. 
  • Epidemiology
    • Incidence
      • peak incidence is 4th and 5th decades
      • lifetime prevalence of 10%
      • only ~5% become symptomatic
    • Demographics
      • 3:1 male:female ratio
    • Location
      • L5/S1 most common level
      • 95% involve L4/5 or L5/S1 levels
  • Etiology
    • Pathoanatomy
      • recurrent torsional strain leads to tears of the outer annulus which leads to herniation of nucleus pulposis
      • lateral edge of posterior longitudinal ligament weakest region
        •  common site for posterolateral/paracentral disc herniations
      • sinuvertebral nerves provide pain innervation to the posterior annulus
        • mediate vertebrogenic back pain that precedes or accompanies disc herniation 
    • Pathophysiology
      • cellular senescence of fibrochondrocytes leads to loss of proteoglycan production leading to disc height loss 
        • loss of height causes increased strain on the annulus fibrosus
        • increased strain leads to fissures of the annulus fibrils 
      • annular tears compromise hoop stresses that act against the deforming forces of the nucleus pulposus
      • nucleus pulposus herniates through tear
        • younger, well-hydrated discs more likely to herniate
          •  pediatric patients may have Salter-Harris II fracture of the ring apophysis
        • older, desiccated discs less likely to herniate
      • sciatica symptoms result from combined mechanical compression and associated inflammation
        • not all patients with mechanical compression develop symptoms 
          • TNF-α, MMP, NO, PE2, and IL-6 are implicated in nerve irritation leading to radiculopathy
            • weak evidence to support DMARDs for treatment
  • Anatomy
    • Complete intervertebral disc anatomy and biomechanics
    • Disc composition
      • annulus fibrosis
        • composed of type I collagen, water, and proteoglycans
          • 15-25 sheets of lamellae
        • characterized by extensibility and tensile strength
          • high collagen / low proteoglycan ratio (low % dry weight of proteoglycans)
      • nucleus pulposus
        • composed of type II collagen, water, and proteoglycans
        • characterized by compressibility
          • low collagen / high proteoglycan ratio (high % dry weight of proteoglycans)
            • proteoglycans interact with water and resist compression
          • a hydrated gel due to high polysaccharide content and high water content (88%)
            • disc height dependent on the degree of hydration 
        • avascular structure
          • nutrients supplied by diffusion from the end plates
    • Nerve root anatomy
      • key difference between cervical and lumbar spine is
        • pedicle/nerve root mismatch
          • cervical spine C6 nerve root travels under C5 pedicle (mismatch)
          • lumbar spine L5 nerve root travels under L5 pedicle (match)
          • extra C8 nerve root (no C8 pedicle) allows transition
        • horizontal (cervical) vs. vertical (lumbar) anatomy of nerve root
          • because of vertical anatomy of lumbar nerve root a paracentral and foraminal disc will affect different nerve roots
          • because of horizontal anatomy of cervical nerve root a central and foraminal disc will affect the same nerve root
  • Classification
    • Location Classification
      • central prolapse
        • often associated with back pain only
        • may present with cauda equina syndrome which is a surgical emergency
      • posterolateral (paracentral)
        • most common (90-95%)
        • PLL is weakest here
      • foraminal (far lateral, extraforaminal)
        • less common (5-10%)
        • affects exiting/upper nerve root
          • at L4/5 affects L4 nerve root
        • herniated disc material directly compresses dorsal root ganglion
          • can manifest with more severe pain than traditional posterolateral disc herniation
      • axillary
        • can affect both exiting and descending nerve roots
    • Morphology classification
      • protrusion
        • eccentric bulging with an intact annulus
      • extrusion
        • disc material herniates through annulus but remains continuous with disc space
      • sequestered fragment (free)
        • disc material herniates through annulus and is no longer continuous with disc space
        • prone to proximal or distal migration
    • Containment classification
      • contained 
        • disc material is contained beneath the posterior longitudinal ligament
      • uncontained
        • disc material passes dorsal to the posterior longitudinal ligament
    • Timing classification
      • acute
        • herniations present < 3-6 months
          • important consideration given surgical outcomes are associated with chronicity 
      • chronic
        • herniations present >6 months
  • Presentation
    • History
      • sudden onset of pain after lifting a heavy object
      • occupational exposure
        • prolonged sitting with lateral bending and rotation in the presence of vibrational energy
      • symptomatic improvement lying supine with knees and hips flexed
        • especially with lower lumbar disc herniations
    • Symptoms
      • can present with symptoms of
        • axial back pain (low back pain)
          • this may be discogenic or mechanical in nature
          • can precede herniation 
        • radicular pain (buttock and leg pain)
          • often worse with sitting, improves with standing
          • symptoms worsened by coughing, valsalva, sneezing
          • pain not worsened with ambulation 
        • cauda equina syndrome (present in 1-10%)
          • bilateral leg pain
          • LE weakness
          • saddle anesthesia
          • bowel/bladder symptoms
    • Physical exam
      • inspection
        • limited lumbar range of motion
          • often the pain is the limiting factor
        • patient leaning away from side of radiculopathy
          • effort to increase the size of the neuroforamen
      • palpation
        • spasms of the paraspinal musculature
          • nonspecific
        • associated tenderness in the paraspinal musculature
          •  nonspecific 
      • motor exam & reflexes
        • see lower extremity neuro exam
          • L3 radiculopathy
            • hip adduction weakness
            • knee extension weakness
            • dermatomal pain in the anteromedial thigh
          • L4 radiculopathy
            • ankle dorsiflexion weakness (L4 > L5)
            • decreased patellar reflex
            • dermatomal pain in the lateral thigh, crossing the knee, to medial foot
          • L5 radiculopathy
            • EHL weakness (L5)
              • manual testing
            • ankle dorsiflexion weakness (L4 > L5 contribution)
              • test by having patient walk on heels
            • ankle inversion weakness
            • hip abduction weakness (L5)
              • have patient lie on side on exam table and abduct leg against resistance
            • dermatomal pain in anterolateral leg and dorsum of foot
          • S1 radiculopathy
            • ankle plantar flexion weakness (S1)
              • have patient do 10 single leg toes stands
            • decreased Achilles tendon reflex
            • dermatomal pain in posterior calf and lateral foot
      • provocative tests
        • straight leg raise (Lasegue's sign)
          • a tension sign for L4, L5 and S1 nerve root
          • technique
            • can be done sitting or supine
            • reproduces pain and paresthesia in leg at 30-70 degrees hip flexion
          • sensitivity/specificity
            • most important and predictive physical finding for identifying who is a good candidate for surgery
        • contralateral SLR
          • crossed straight leg raise is less sensitive but more specific
        • femoral nerve stretch test (Wasserman sign)
          • tension sign for L2 and L3
          • performed in prone position
            • knee flexed and hip exteneded
            • reproduction of pain in anterior thigh is considered positive
        • Braggard's sign
          • perform SLR to the point of exacerbation
          • lower leg just to the point where pain recedes
            • ankle dorsiflexion causes exacerbated pain
        • Bowstring sign
          • SLR aggravated by compression on popliteal fossa
        • Kernig test
          • pain reproduced with neck flexion, hip flexion, and leg extension
        • Naffziger test
          • pain reproduced by coughing, which is instigated by lying patient supine and applying pressure on the neck veins
        • Milgram test
          • pain reproduced with straight leg elevation for 30 seconds in the supine position
      • gait analysis
        • Trendelenburg gait
          • due to gluteus medius weakness which is innervated by L5
  • Imaging
    • Radiographs
      • recommended views
        • AP and lateral radiographs
          • helpful for surgical localization 
            • identify anomalous vertebrae (sacralized L5 or lumbarized S1)
      • optional views
        • flexion-extension
          • identifies instability
            • if present can changes surgical plan to involve fusion
      • findings
        • most often normal 
        • abnormal findings
          • loss of lordosis (spasm)
          • loss of disc height
            • especially at the involved level
          • lumbar spondylosis (degenerative changes)
            • facet hypertrophy
            • disc space collapse
            • peridiscal osteophytes
          • sciatic scoliosis
            • convex or concave list to the ipsilateral side of herniation
      • sensitivity 
        • poor sensitivity for identifying disc herniation
        • more often used as a screening tool for other pathology prior to proceeding with MRI
    • CT myelogram
      • indications
        • patients unable to obtain MRI 
          • pacemaker
      • views
        • sagittal and coronal reconstructions demonstrate compression of the thecal sac
      • findings
        • myelography filling defect at the level of herniation
        • a calcified disc may be visible
      • sensitivity
        • 93% accurate at detecting associated surgical pathology
        • unable to detect foraminal or extraforaminal herniations
    • MRI without gadolinium
      • indications for obtaining an MRI
        • pain lasting > one month and not responding to nonoperative management or
        • red flags are present
          • infection (IV drug user, h/o of fever and chills)
          • tumor (h/o or cancer)
          • trauma (h/o car accident or fall)
          • cauda equina syndrome (bowel/bladder changes)
      • modality of choice for diagnosis of lumbar disc herniations
        • highly sensitive and specific
        • helpful for preoperative planning
        • useful to differentiate from synovial facet cysts
      • however high rate of abnormal findings on MRI in normal people
        • need to correlate MRI findings with symptoms and physical exam findings
      • views
        • sagittal and coronal T2 reconstructions
          • localize the level and side of the herniation
          • location anatomic location (central vs paracentral vs foraminal vs extraforaminal)
    • MRI with gadolinium
      • indications
        • useful for revision surgery
      • findings
        • allows to distinguish between post-surgical fibrosus (enhances with gadolinium) vs. recurrent herniated disc (does not enhance with gadolinium)
  • Treatment
    • Nonoperative
      • rest and physical therapy, anti-inflammatory medications, and limited narcotics 
        • indications
          • first line of treatment for most patients with disc herniation
            • new-onset radicular pain
            • no significant motor weakness
            • absence of cauda equina syndrome
            • no bowel/bladder incontinence
        • outcomes
          • 90% improve without surgery
          • positive predictors of good outcomes with nonoperative treatment
            •  higher level of education
      • selective nerve root corticosteroid injections
        • indications
          • second line of treatment if therapy and medications fail
            • usually after 6 weeks
        • outcomes
          • leads to long lasting improvement in ~ 50% (compared to ~90% with surgery)
          • results best in patients with extruded discs as opposed to contained discs
          • no difference in pain relief using lidocaine with and without steroids
    • Operative
      • laminotomy and discectomy (microdiscectomy)
          • persistent disabling pain lasting more than 6 weeks that have failed nonoperative options (and epidural injections)
            • timing of appropriate nonoperative treatment varies
            • better surgical outcomes if addressed within 2 months
          • progressive and significant weakness
          • cauda equina syndrome
        • rehabilitation
          • patients may return to medium to high-intensity activity at 4 to 6 weeks
        • outcomes
          • outcomes with surgery compared to nonoperative
            • improvement in pain and function greater with surgery
            • early and sustained pain relief out to 2 years
            • equal likelihood of receiving disability at 5 years 
          • positive predictors for good outcome with surgery
            • leg pain is chief complaint
            • positive straight leg raise
            • weakness that correlates with nerve root impingement seen on MRI
            • married status
            • progressively worsening symptoms prior to surgery 
            • professional athletes
              • younger age, greater number of games played prior to injury
            • paracentral and foraminal herniations
              • central and extraforaminal associated with worse outcomes 
            • herniation at caudal levels
              • L5-S1 results in better outcomes than L2-3
          • negative predictors for good outcome with surgery
            • worker's compensation
              • WC patients have less relief from symptoms and less improvement in quality of life with surgical treatment
            • smokers
            • chronic headaches
            • depression
      • far lateral microdiskectomy
        • indications
          • for far-lateral disc herniations
  • Techniques
    • Rest and physical therapy, anti-inflammatory medications, and limited narcotics 
      • bedrest followed by progressive activity as tolerated
        • historical treatment
          • most modern protocols involve immediate activity with modification to avoid pain exacerbation 
      • medications
        • NSAIDS
        • muscle relaxants (more effective than placebo but have side effects)
        • oral steroid taper
          • modest but significant improvement in function, no significant improvement in pain
        • narcotic medications
          • typically avoided due to complication profile
            • dependence
            • difficult post-op pain control
            • worse outcomes following surgical treatment
          • if used, usually for a short period (2-3 days) in the acute setting
      • physical therapy
        • typically initiated three weeks after symptom onset
        • extension exercises are extremely beneficial
        • traction
        • chiropractic manipulation
          • should be performed with care
    • Selective nerve root corticosteroid injections 
      • epidural
      • selective nerve block
        • can be therapeutic and diagnostic 
          • useful in case of diagnostic dilemmas 
    • Laminotomy and discectomy (microdiscectomy)
      • various techniques available
        • most techniques can be performed in a "minimally invasive" fashion
          • can be done with small incision or through "tube" access
          • open technique using a crank (McCulloh) retractor
        • discectomy performed through microscope or loupe magnification
          • no difference in outcomes between the two
        • endoscopic techniques available
          • provide smaller incisions
        • similar outcomes between all techniques surgical techniques
        • fragment excision vs extended disc space curettage (subtotal discectomy) 
          • lower long term back pain with fragment excision
          • higher reherniation rates with fragment excision at 2-years follow-up
    • Far lateral microdiskectomy 
      • utilizes a paraspinal approach of Wiltse
        • can also be done with tubular or crank retractors
  • Complications 
    • Dural tear
      • occurs in 0-4% of cases
      • treatment
        • if have tear at time of surgery then perform water-tight repair
          • has not been shown to adversely affect long term outcomes
    • Recurrent HNP
      • defined as recurrent sciatica at the same operated level
        •  pain-free interval of 6 months prior to recurrence of symptoms
        • pathology can be ipsilateral to contralateral to the index presentation 
      • recurrence rate 5-15%
        • revision rate at 8-year follow-up is 15% according to the SPORT trial
        • risk factors protective against recurrent herniation
          • discrete herniations
          • small annular defects (<6 mm)
      • treatment
        • can treat nonoperatively initially
        • revision microdiscectomy in patients with persistent symptoms
          • outcomes for revision discectomy have been shown to be as good as for primary discectomy
    • Wound infections
      • occurs in up to 3% of cases
        • epidural abscess in 0.3% of cases
      • risk factors
        • microscope usage proposed as a source of infection
          • some date refutes this claim
      • treatment
        • superficial infections
          • treat with local wound care and antibiotics
        • deep infections
          • surgical I&D
    • Epidural fibrosis
      • scarring the compresses the dura leading to radicular symptoms
        • associated with poor outcomes following revision surgery
          • persistent back pain
          • patients 3.2 times more likely to suffer from recurrent radiculopathy
      • MRI may demonstrate retraction of the dura on the side of the lesion
    • Pyogenic discitis 
      • occurs in 2.3% of cases
      • treatment
        • IV antibiotics +/- surgical I&D
    • Chronic low back pain
      • not completely understood but central sensitization may be a factor
        • amplification of neural signaling within the central nervous system (CNS) that elicits pain hypersensitivity.
      • Modic changes on MRI imaging are associated with post-operative back pain 
      • Pain diagrams may be useful in identifying patients with an increased likelihood of pain sensitization, psychosocial load, and utilizing pain management resources
    • Vascular catastrophe
      • exceedingly rare
      • caused by breaking through anterior annulus and injuring vena cava/aorta
      • treatment
        • immediate recognition of complication followed by coordinated repair by vascular service
    • Instability
      • due to over resection of lamina and pars interarticularis
      • not all patients are symptomatic
      • treatment
        • instrumentation and fusion of the affected segment
  • Prognosis
    • Natural history
      • 90% of patients will have improvement of symptoms within 3 months without substantial medical treatment
        • patients less likely to improve if still symptomatic after 6 weeks
      • factors associated with good outcomes with nonoperative treatment
        • lack of radiculopathy
      • factors associated with worse outcomes with nonoperative treatment
        •  obese patients (BMI >30)
        • symptoms present >6 months prior to starting treatment
    • Size of herniation decreases over time (reabsorbed)
      • sequestered disc herniations show the greatest degree of spontaneous reabsorption
      • macrophage phagocytosis and enzymatic degradation is the mechanism of reabsorption
    • Factors associated with favorable surgical outcomes
      • severe preoperative leg pain
      • shorter symptom duration
      • younger age
      • increased preoperative physical activity
    • Surgical treatment is equivalent to nonsurgical treatment in the long term
      • surgery provides faster pain relief

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(OBQ19.152) A 47-year-old man presents for consultation for "potential spine surgery" after referral from his chiropractor. The diagram in Figure A is included in his intake packet. Which of the following statements is most accurate about this diagram?

QID: 214054
FIGURES:

The level of pain depicted on the diagram is inversely proportional to the level of anxiety

1%

(8/1305)

The level of pain depicted on the diagram negatively correlates with the level of depression

1%

(18/1305)

It is a moderately sensitive tool to identify patients who will or will not benefit from surgery

14%

(177/1305)

It is a convenient screening tool to identify patients with an increased likelihood of pain sensitization, psychosocial load, and utilizing pain management resources

78%

(1018/1305)

It is a moderately specific tool to identify patients who will or will not benefit from surgery

5%

(71/1305)

L 2 A

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(SBQ18SP.40) A 39-year-old seasoned professional football player sustains an injury to his lower back during off-season training. Figure 1 and 2 show the pertinent MRI findings. Which of the following is true?

QID: 211542
FIGURES:

Age at the time of injury is a positive predictor of career length and the ability to return to sport.

28%

(470/1663)

Following this injury, the likelihood of remaining active within professional sports remains relatively constant over the first 2 years from injury.

35%

(579/1663)

The number of games played prior to injury is a positive predictor of ability to return to play following this injury.

27%

(453/1663)

This patient is more likely to return to play than players of another professional sport.

2%

(36/1663)

This patient would experience less of a treatement effect from surgery compared to players of other professional sports.

7%

(112/1663)

L 5 A

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(OBQ18.95) A 44-year-old patient is presenting with right dorsal foot pain, loss of sensation, and weakness that started 3 weeks ago after moving large heavy boxes from his friend's apartment. Coughing and the Valsalva maneuver make the pain worse. Which physical exam finding would suggest peroneal nerve palsy instead of L5 radiculopathy?

QID: 212991

Weak ankle plantarflexion

8%

(169/2111)

Weak ankle dorsiflexion

34%

(724/2111)

Intact ankle inversion

46%

(975/2111)

Intact ankle eversion

10%

(204/2111)

Weak knee extension

1%

(27/2111)

L 1 A

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(SBQ18SP.62) Figure 1 is the axial MRI image of the L5-S1 level from a patient with weakness, and left leg pain. Which muscle function would be most likely to be affected in this patient?

QID: 211784
FIGURES:

Hip flexion

2%

(33/1961)

Hip adduction

2%

(48/1961)

Hip abduction

51%

(994/1961)

Knee Extension

5%

(93/1961)

Ankle plantarflexion

40%

(782/1961)

L 5 A

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(OBQ13.271) A 45-year-old female returns to your clinic with 10-weeks of severe pain that starts in her back and extends down her right leg to the top of her foot. On physical exam she has decreased sensation on the dorsal aspect of her foot and 4/5 strength in her EHL. She has a positive straight leg raise on the right. The remaining physical exam is unremarkable, including normal achilles and patellar reflexes bilaterally, no clonus, and a down-going Babinski sign. Her pain has not been relieved by NSAIDs, epidural steroids or physical therapy. Figure A is a sagittal MRI and figure B is a axial MRI through the L4/5 disc space. What is the best treatment option at this time?

QID: 4906
FIGURES:

Continued oral anti-inflammatories

3%

(88/3186)

Right L4/5 microdiscectomy

91%

(2910/3186)

Right L4/5 minimally invasive transforaminal interbody fusion

2%

(49/3186)

Referral for EMG and nerve conduction studies

1%

(22/3186)

L4/5 posterior decompression and instrumented fusion

3%

(98/3186)

L 1 A

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(OBQ13.27) A 35-year-old physical therapist presents with right-sided back and leg pain. For the last 4 months, he has taken anti-inflammatory medications and performed exercises on his own. While his back pain has improved slightly, his leg pain remain severe and interferes with his ability to sleep and work. Examination reveals positive ipsilateral and contralateral straight leg raise at 30 degrees. He has mildly diminished big toe dorsiflexion strength on the right side. There is a small patch of diminished sensation on the dorsum of the foot. MRI scans are shown in Figures A and B. What is the most appropriate next step in treatment?

QID: 4662
FIGURES:

Continued rest, formal physical therapy and anti-inflammatory medications

6%

(246/4468)

Targeted chemonucleolysis of the L4-5 disc

1%

(37/4468)

Discectomy and interbody fusion L4-5

6%

(277/4468)

Discectomy utilizing a midline approach between the spinous process and multifidus

72%

(3217/4468)

Discectomy utilizing an intermuscular approach between multifidus and longissimus

15%

(663/4468)

L 3 B

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(SBQ12SP.99) A 45-year-old man presents to clinic with low back and lower extremity pain. He also complains of weakness in the lower extremity. His MRI is shown in Figure A. Which muscle would you most likely expect to be weak in this patient?

QID: 3797
FIGURES:

Extensor hallucis longus

3%

(68/1950)

Tibialis anterior

77%

(1511/1950)

Gastrocnemius

2%

(34/1950)

Psoas major

16%

(312/1950)

Flexor hallucis longus

1%

(14/1950)

L 3 A

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(OBQ12.230) A 38-year-old male presents with a three month history of low back pain and right leg pain that has failed to improve with nonoperative modalities including selective nerve root corticosteroid injections. He reports pain and paresthesias to the right buttock, posterolateral lower leg and lateral foot. On strength testing, he has graded 5/5 strength to knee extension, 5/5 ankle dorsiflexion and 4/5 ankle plantar flexion. Flexion and extension radiographs show no evidence of spondylolisthesis. Sagittal and axial MRI images are shown in Figure A and B. Which of the following treatment modalities will allow the greatest improvement of physical functioning?

QID: 4590
FIGURES:

Observation alone

1%

(40/3632)

Physical therapy

3%

(100/3632)

Medical management with GABA analogs

1%

(33/3632)

Discectomy

84%

(3056/3632)

Disectomy and instrumented fusion

10%

(363/3632)

L 2 A

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(SBQ12SP.14) A 36-year-old male presents with acute onset of right buttock and leg pain following lifting a heavy object. On physical exam he has weakness to knee extension, numbness over the medial malleolus, and a decreased patellar reflex. Which of the following would most likely explain this clinical presentation.

QID: 3712

Lumbar arachnoiditis

0%

(10/4929)

L4/L5 paracentral disc herniation

4%

(183/4929)

L3/L4 far lateral (foraminal) disc herniation

17%

(852/4929)

L4/L5 far lateral (foraminal) disc herniation

77%

(3798/4929)

L5/S1 far lateral (foraminal) disc herniation

1%

(57/4929)

L 1 A

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(SBQ12SP.8) A 45-year-old patient complains of leg pain associated with the pathology seen in Figure A. The patient undergoes microdiskectomy. During surgery there is no evidence of instability. Ten months later he
re-develops similar symptoms of leg pain. A repeat MRI is consistent with a recurrent lumbar disc herniation. Which of the following most accurately describes the outcomes of revision surgery in comparison to primary surgery?

QID: 3706
FIGURES:

Equal limb pain and equal functional outcomes

55%

(3016/5474)

Improved limb pain and improved functional outcomes

11%

(612/5474)

Worsened limb pain and worsened functional outcomes

15%

(832/5474)

Worsened limb pain but improved functional outcomes

1%

(81/5474)

Improved limb pain but worsened functional outcomes

16%

(901/5474)

L 4 C

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(OBQ12.102) In patients with a symptomatic lumbar disc herniation who have failed nonoperative management, which of the following patient characteristics are associated with improved treatment effects with surgery?

QID: 4462

Duration of symptoms > 6 mos, improving symptoms at baseline, Mental Component Score (MCS) > 35

8%

(355/4666)

Duration of symptoms < 6 mos, worsening symptoms at baseline, Mental Component Score (MCS) > 35

18%

(846/4666)

Age > 41 years, divorced, presence of worker compensation claim

1%

(51/4666)

Age < 31 years, absence of joint problems, no workers compensation

37%

(1721/4666)

Age > 41 years, absence of joint problems, married status

35%

(1654/4666)

L 5 B

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(OBQ11.236) A 35-year-male presents with pain radiating down the left leg, worse in the anterior leg distal to the knee. On physical exam, he is unable to go from a sitting position to a standing position with a single leg on the left, whereas he has no difficulty on the right. His patellar reflex is absent on the left, and 2+ on the right. Which of the following clinical scenarios would best produce this pattern of symptoms?

QID: 3659

Left L2-3 foraminal herniated nucleus pulposis

8%

(336/3979)

Left L4-5 central herniated nucleus pulposis

3%

(124/3979)

Left L4-5 paracentral herniated nucleus pulposis

11%

(420/3979)

Left L4-5 foraminal herniated nucleus pulposis

76%

(3019/3979)

Left L5-S1 paracentral herniated nucleus pulposis

1%

(55/3979)

L 1 C

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(OBQ11.65) A 33-year-old woman reports pain down her right leg and numbness across the dorsum of her right foot which started 3 months ago during a bowel movement. Prior to this she had had 1 month of low back pain. She had a lumbar microdiscectomy at L4/5 3 years ago which was successful. On physical exam she has weakness to ankle dorsiflexion and great toe extension on the right. Her new radiograph and MRI images are shown in Figure A and B respectively. After a failure of nonoperative treatment, which of the following is the most appropriate surgical treatment?

QID: 3488
FIGURES:

L4/5 microdiskectomy through midline approach

70%

(2569/3662)

L4/5 microdiskectomy with far lateral Wiltse approach

7%

(252/3662)

L4/5 Decompression, TLIF, and instrumented fusion

7%

(267/3662)

L4/5 Decompression, PLIF, and instrumented fusion

14%

(496/3662)

L4/5 Anterior Lumbar Interbody Fusion

1%

(49/3662)

L 3 C

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(OBQ10.18) Following surgical treatment of a lumbar disc herniations with radiculopathy, patients with worker's compensation claims have which of the following when compared to patients who do not have worker's compensation claims at 5 years?

QID: 3106

Equivalent relief from symptoms and equivalent improvement in quality of life

3%

(76/2617)

Less relief from symptoms and less improvement in quality of life

68%

(1767/2617)

Improved relief from symptoms and greater improvement in quality of life

2%

(49/2617)

Significantly decreased return to work status

26%

(681/2617)

Significantly improved return to work status

1%

(30/2617)

L 1 C

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(OBQ09.206) A 40-year-old female presents with right leg pain localized to the buttock, posterior thigh, and lateral calf. In addition, she describes numbness and tingling on the dorsum of the right foot. Physical exam shows weakness to EHL. Three months of nonoperative treatment including anti-inflammatory medication, physical therapy, and selective nerve root corticosteroid injections failed to provide lasting relief and pain is still severe in nature. Her MRI is shown in Figures A and B. What would be the most appropriate management at this juncture?

QID: 3019
FIGURES:

Refer the patient to pain management

0%

(10/3087)

Repeat epidural steroid injection

1%

(16/3087)

Transforaminal diskectomy

9%

(271/3087)

Laminotomy and diskectomy

87%

(2681/3087)

Spinal fusion with interbody cage and posterior instrumentation

3%

(93/3087)

L 1 B

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(SAE08AN.31) What structure is located at the tip of the arrow in Figure 18?

QID: 6191
FIGURES:

Left L3 nerve root

3%

(23/815)

Right L3 nerve root

79%

(643/815)

Right L4 segmental artery

8%

(69/815)

Right L4 nerve root

9%

(72/815)

Left lateral disk herniation

0%

(2/815)

L 2 E

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(OBQ08.158) In patients with lumbar disc herniations resulting in significant unilateral leg pain but no functionally limiting weakness, surgical decompression has what long term effects when compared to nonoperative management?

QID: 544

Worse outcomes in pain, physical function, and return to work status at 4 years.

3%

(64/2085)

Equivalent outcome in pain and physical function at 4 years.

40%

(829/2085)

Improved outcome in pain and physical function at 4 years.

50%

(1050/2085)

Improved outcome in return to work status only at 4 years.

2%

(32/2085)

Worse outcome in return to work status with equivalence in pain and physical function at 4 years.

5%

(96/2085)

L 4 B

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(OBQ06.43) 45-year-old manual laborer presents to the office with acute onset back pain that radiates to his right leg after carrying a heavy object. He also has mild non-progressive weakness with ankle dorsiflexion on that side. A representative MRI cut is shown in Figure A. What should be his initial treatment?

QID: 154
FIGURES:

Microdiskectomy

7%

(213/3077)

Posterior spinal fusion with instrumentation

1%

(16/3077)

Decompression only

3%

(78/3077)

Strict bedrest

1%

(21/3077)

Anti-inflammatory medication and physical therapy

89%

(2724/3077)

L 1 C

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Evidence (91)
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EXPERT COMMENTS (42)
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